627a 16 year old male is admitted to the pediatric

627.A 16-year-old male is admitted to the pediatric intensive care unit
after being involved in a house fire. He has full thickness

burns to his lower torso and extremities. Before a dressing change to
his legs, which intervention is most important for the nurse to im-
plement?
a. Encourage the parents to stay at the bedside
b. Use distraction techniques to reduce pain.
c. Maintain strict aseptic technique
d. Place a drape over the pubic area.
Rationale: Full thickness burns cause destruction of the epidermis,
dermis… minimize post burn colonization of the wound with gram-
negative opportunistic organism is necessary to maintain strict aseptic
technique is essential during dressing changes.
628.While performing a skin inspection for a female adult client, the
nurse observes a rash that is well circumscribed, has silvery scales
and plaques, and is located on the elbows and knees. These assess-
ment findings are likely to indicate which condition?
a. Tinea corporis
b. Herpes zoster
c. Psoriasis

d. Drug reaction
Rationale: Psoriasis is typically located on the elbow and knees.
629.A client with acute pancreatitis is complaining of pain and nausea.
Which interventions should the nurse implement (Select all that ap-
ply)
a. Monitor heart, lung, and kidney function.
b. Notify healthcare provider of serum amylase and lipase
levels.
c. Position client on abdomen to provide organ stability
d. Encourage an increased intake of clear oral fluids
e. Review client’s abdominal ultrasound findings.
Rationale: Client’s heart, lungs and kidney can be damage by en…of
pancreatitis, so it is important to monitor de function of these organs.
High levels of lipase ad amylase are signs of pancreatic damage or in-
flammation. Ultrasound is the initial diagnostic test to determine the
cause of pancreatitis. Positioning the abdomen may cause abdominal
pressure and oral fluids should be withheld until nauseas subsides.
630.A nurse is caring for a client with Diabetes Insipidus. Which as-
sessment finding warrants immediate intervention by the nurse?

a- Hypernatremia
b- Excessive thirst
c. Elevated heart rate
d. Poor skin turgor
Rationale: A deficiency of antidiuretic hormone (ADH) is the underlying
cause of DI, which results in… hypotonic urine.
631.In caring for a client receiving the amino glycoside antibiotic
gentamicin, it is most important for the nurse to monitor which di-
agnostic test?
a. Urinalysis
b. Serum creatinine
c- Serum osmolarity
d- Liver enzymes.
Rationale: Aminoglycosides can cause nephrotoxicity, so it is important
for the nurse to monitor the serum creatinine level can monitor the renal
function.
632.The nurse weighs a 6-month-old infant during a well-baby check-
up and determines that the baby’s weight has tripled compared to
the birth weight of 7 pounds 8 ounces. The mother asks if the baby
is gaining enough weight. What response should the nurse offer?